1. (1) Community residential habilitation service planning shall be initiated based on documentation that services are necessary to meet the person's needs, and a determination that the person meets the requirements for eligibility at section 671.4(a)(2) of this Part.
2. (2) The parties to be involved in the development of a plan of services to provide services shall include the person, an advocate (see glossary), the assigned qualified intellectual disabilities professional (QIDP; see glossary), the person's case manager, the staff member(s) principally responsible for the delivery of the person's plan of services, with an invitation to the person's parent or guardian as long as the person does not object to said parties' participation.
3. (3) There shall be a designated qualified intellectual disabilities professional (QIDP; see glossary) responsible for approving the plan of services of every person receiving services. The QMPR shall be identified by name in each person's plan of services.

4. (4) The QIDP shall be responsible for:

   1. (i) participating in the development of the person's plan of services;
   2. (ii) signing the plan of services;
   3. (iii) participating in the semi-annual review of each person's plan of services;
   4. (iv) completing the annual summary assessment of the person's status relative to his/her receipt of community residential habilitation services over the previous 11 months; and
   5. (v) periodically ensuring that the plan of services is being appropriately documented in accordance with the requirements of this Part.

5. (5) Each provider authorized to deliver community residential habilitation services shall conduct a program planning process in accordance with the requirements set forth in this Part and in accordance with its own policies and/or procedures (see glossary). The program planning process shall, at least, include:

   1. (i) a meeting of, and/or sharing of appropriate information from, the appropriate parties;
   2. (ii) consideration of appropriate clinical and developmental assessments;
   3. (iii) consideration of the person's input relative to choices about how his/her needs and interests are to be met; and
   4. (iv) development of a written plan of services that includes components set forth at paragraph (6) of this subdivision.

6. (6) A community residential habilitation plan of services shall be written, developed within 30 days of initiation of such services and shall set forth a mutually agreed upon course of action which shall include at least the following components:

   1. (i) Identification of the specific community residential habilitation services to be delivered, any associated activities, interventions and/or therapies, and the use of therapeutic leave to further enhance service outcomes.

   2. (ii) The outcomes to be achieved through the provision of each of the community residential habilitation services to be delivered. Such outcomes shall include consideration of promoting achievement of the following goals consistent with the services being provided:

      1. (a) Independence—the person has opportunities to develop capacities that lessen his/her dependence.
      2. (b) Integration—the person has opportunities to engage in experiences and activities with those who are not disabled.
      3. (c) Individualization—the person is given meaningful choices, respected, addressed and provided services in terms of his/her unique and valued individuality.
      4. (d) Productivity—the person is provided opportunities to make an increasingly meaningful contribution to his/her living and community environment.
   3. (iii) Specification of generally when the specified outcomes will be achieved.
   4. (iv) Efforts to coordinate the provision of services with other providers of such services and/or other supports being received.
7. (7) The plan of services shall be delivered by appropriately trained and supervised staff of the facility.

8. (8) Progress notes shall be recorded, at least monthly, by the staff member(s) having a substantive responsibility for delivering or monitoring delivery of the plan of services. Such notes shall:

   1. (i) indicate the activities and interventions provided;
   2. (ii) indicate “when appropriate and as indicated” in the individual's plan of services, review and assessment by the QIDP;
   3. (iii) identify any significant events or noteworthy observations relevant to the person's receipt of the service(s); and
   4. (iv) set forth any recommendations for changes in any aspect of the plan of services and actions to be taken to effect such change.

9. (9) The plan of services shall be reviewed as needed, but at least semi-annually, with the initial review occurring within a semi-annually period from the date of service initiation. The review shall include participation of the person, his/her advocate, his/her case manager, the designated QIDP, the staff member(s) primarily responsible for actual service delivery, and an invitation to the person's parent or guardian (unless the person objects) to participate. The semi-annual review of the plan of services shall include:

   1. (i) an evaluation of the person's progress in achieving the specified outcomes;
   2. (ii) an evaluation of the person's satisfaction with the activities, interventions and/or therapies being provided; and
   3. (iii) recommendations for revision of outcomes, or selection of different outcomes and/or activities, interventions or therapies and specification of the appropriate timeframes for achievement of the revised/changed outcomes.
10. (10) The plan of services shall be maintained with a concern for confidentiality and the protection of each person's right to privacy. The preceding notwithstanding, the person's plan of services shall be accessible, at the service delivery setting, or readily available to staff members responsible for its implementation.
11. (11) In settings where services are authorized, it is expected that service(s) will be available daily, but delivered in accordance with the individualized plan of services, throughout a month. Persons receiving services are permitted and encouraged to participate in periodic away-from-service-setting visits with family and friends and overnight recreational opportunities.

12. (12) Services shall be delivered by appropriately trained and supervised staff members who, in accordance with their assigned responsibilities, are familiar with each person's needs and the activities, interventions, and/or therapies associated with the rehabilitative service(s) being provided.

    (b) Standards of certification.

13. (1) OPWDD shall verify that the person directly participated in the program planning process for the development of the community residential habilitation service(s) identified in his/her plan of services.
14. (2) OPWDD shall verify that each person receiving community residential habilitation services has been assigned a qualified mental retardation professional.
15. (3) OPWDD shall verify in both the service planning and service delivery aspects, that the provider of community residential habilitation services has respected the person's cultural and language needs and has attempted to ensure that the person's primary language or means of communication has been used to facilitate learning and understanding.
16. (4) OPWDD shall verify that the provider has incorporated in both the service planning and service delivery aspects, outcomes that include attention to the concepts of individualization, integration, independence and productivity.

(a) Principles of compliance.